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PROOF OF INSURANCE (2018 - 2019) CLOSED ACCORV DATE(MLVDDNYYY) CERTIFICATE OF LIABILITY INSURANCE I 3/6/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy((es)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endomement(s). PRODUCER CONTACT Elizabeth Flinders NAME. I Flinders/D@Palma Insurance Agency PHO N0 Ext); (818)843-8600 FAX No):(818)566-9841 License #0447329 DDRL AESS:liz®flindersins.com ADDR P.O. Box 510 INSURER(S)AFFORDING COVERAGE NAIC A Burbank CA 91503 INSURERA Mesa Underwriters Speciality 36838 INSURED INSURERB:Progressive/United Financial Co. 11770 INSURER C: Clean Scene Services INSURER D: 9909 Escondido Cyn Rd. INSURER E: Agus Dulce CA 91390 INSURER F: COVERAGES CERTIFICATE NUMBER MCert 2018-19 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILLTNR ADDL'SUBR POLICYEFF R TYPE OF INSURANCE POLICY NUMBER IMMID'DPMYI POLICY EXP 'IMMdDD1YY'YY) LIMITS A X COMMERCIAL GENERAL LIABILITY M0004018003190 02/06/2018 02/06/2019 EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X DAMAGE TO RENTED OCCUR PREMISES(Ea occurrence) $ 100,000 X MED EXP(Any one person) $ S'000 PERSONAL BADV INJURY $ 1,000,000 GEN"L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 X 'POLICY E E] LOC PRODUCTS-COMP/OP AGG $ included OTHER $ B AUTOMOBILE LIABILITY 06342952-0 11/22/2017 11/22/2018 CO��MaBBII NED SINGLE LIMIT 'I$ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident)dent $ NON-OWNED (PROPERTY RAMAGE $ HIRED AUTOS AUTOS (Petr dcadenl) $ UMBRELLA LIAB OCCUR , EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION PER O'TH- AND EMPLOYERS'LIABILITY YIN STATUTE „ER ANY PROPRIETORIPARTNERIEXECUTIVE NIA EL EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE•EA EMP'LO'YEE$ If as,descnoo under I DESCRIPT Ir ON OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) City of El Segundo is named as an additional insured on the General Liability policy as per written contract. Endorsement attached. 10 day notice of cancellation for non payment of premium. CERTIFICATE HOLDER CANCELLATION. (310)524-2200 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of E1 Segundo THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 348 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. El Segundo, CA 90245 AUTHORIZED REPRESENTATIVE E Flinders/LAF ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) Policy # MP0004018003190 MESA UNDERWRITERS SPECIALTY INSURANCE COMPANY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. LIMITED Al - PRIMARY NON-CONTRIBUTORY - WAIVER OF SUBROGATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM Blanket Additional Insureds -As Required By Contract A. Subject to the Primary and Non-Contributory provision set forth in this endorsement, SECTION II -WHO IS AN INSURED is amended to include as an additional insured any person or organization whom you have agreed in a written contract, written agreement or written permit that such person or organization be added as an additional insured on your policy. Such person or organization is an additional insured only with respect to liability for"bodily injury"or"property damage" or, to the extent applicable under the Coverage Part to which this endorsement applies, "personal and advertising injury"caused, in whole or in part, by: 1. Your ongoing operations, "your product", or premises owned or used by you; With respect to the insurance afforded to these additional insureds, the following additional exclusion applies: This insurance does not apply to"bodily injury", "property damage" or, to the extent applicable under the Coverage Part to which this endorsement applies, "personal and advertising injury"arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services by or for you, including: a. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and b. Supervisory, inspection, architectural or engineering activities. This exclusion applies even if the claims against any insured allege negligence or other wrong-doing in the supervision, hiring, employment, training or monitoring of others by that insured, if the"occurrence" which caused the"bodily injury"or"property damage", or,to the extent applicable under the Coverage Part to which this endorsement applies, the offense which caused the"personal and advertising injury", involved the rendering of, or failure to render, any professional architectural, engineering or surveying services. 2. Your maintenance, operation or use of equipment, other than aircraft, "auto"or watercraft, rented or leased to you by such person or organization.A person or organization's status as an additional insured under this endorsement ends when their contract, or agreement with you for such rented or leased equipment ends. With respect to the insurance afforded to these additional insureds, this insurance does not apply to any"occurrence"which takes place after the rental agreement or equipment lease expires. The provisions of this coverage extension do not apply unless the written contract or written agreement has been executed (executed means signed by the named insured)or written permit issued prior to the"bodily injury"or"property damage"or, to the extent applicable under the Coverage Part to which this endorsement applies, "personal and advertising injury". MUS 01 01 20127 0316 INSURED Page 1 of 2 Primary and Non-Contributory Provision The following is added to Paragraph 4.Other Insurance, b. Excess Insurance under SECTION IV- COMMERCIAL GENERAL LIABILITY CONDITIONS: This insurance shall be excess with respect to any person or organization included as an additional insured under this policy, any other insurance that person or organization has shall be primary with respect to this insurance, unless: 1) The additional insured is a Named Insured under such other insurance; 2) You have agreed in a written contract, written agreement or written permit to include that additional insured on your General Liability policy on a primary and/or non-contributory basis; 3) The written contract or written agreement has been executed (executed means signed by the named insured) or written permit issued prior to the"bodily injury"or"property damage"or, to the extent applicable under the Coverage Part to which this endorsement applies, "personal and advertising injury"; and 4) With respect to indemnity, you have been adjudicated liable in full for the"bodily injury" or "property damage" or, to the extent applicable under the Coverage Part to which this endorsement applies, "personal and advertising injury". Waiver Of Transfer Of Rights Of Recovery The following is added to Paragraph 8.Transfer of Rights Of Recovery Against Others To Us under SECTION IV-COMMERCIAL GENERAL LIABILITY CONDITIONS: We will waive any right of recovery we may have against a person or organization because of payments we make for"bodily injury" or"property damage" arising out of your ongoing operations or"your work"done under a written contract or written agreement and included in the"products-completed operations hazard", if: 1. You have agreed to waive any right of recovery against that person or organization in a written contract or written agreement; 2. Such person or organization is an additional insured on your policy; or 3. You have assumed the liability of that person or organization in that same contract, and it is an"insured contract'. The section above only applies to that person or organization identified above, and only if the"bodily injury" or"property damage"occurs subsequent to the execution of the written contract or written agreement. All other terms and conditions of this policy remain unchanged. MUS 01 01 20127 0316 Page 2 of 2 CITY OF EL SEGUNDO WORKERS' COMPENSATION DECLARATION .......�.......................... .m................ .. WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SUBJECTS AN EMPLOYER TO CRI INAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN LABOR CODE § 3706, INTEREST, AND ATTORNEY'S FEES. 1 affirm under penalty of perjury under the laws of California one of the following declarations: (__) I have and will maintain a certificate of consent of self-insure for workers'compensation, issued by the Director of Industrial Relations as provided for by Labor Code§3700 for the performance of the work set forth the agreement with the City of EI Segundo. Policy No. (�}I have and will maintain workers'compensation insurance as required by Labor Code§3700 for the performance of the work for which the agreement with the City of EI Segundo is executed. My workers' compensation insurance carrier and policy number are: Carrier „.., Policy Number Expiration Date Name of Agent Phone# (,�J I certify that, in the performance of the work set forth in the agreement with the City of EI Segundo, I will not employ any person in any manner so as to become subject to the workers' compensation laws of California, and agree that, if I should become subject to the workers' compensation provisions of Labor Code § 3700 1 must immediately comply with those provisions or the agreement will automatically become void. Signature of Applicant - ,°<,ew., d,'' ' ,. :.” .a- ... Date Agreement for: Dated, Reviewed by